Payment Plan Registration Form

Embody Payment Plan

Embodiment Assistant Retreat
Dancer Name*

First NameLast Name
Pronouns
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dancer E-mail*
example@example.com
Dancer Phone Number*
Are you associated with a studio? If so, which one? If not, write "Independent."*
Parent Name (if under 18)

First NameLast Name
Parent Phone Number (if under 18)
Parent Email (if under 18)
example@example.com
Additional Comments

Payment Plan Promissory Note

This form must be filled out by someone 18 years or older. If you are a dance under 18, please pass this along to a parent/legal guardian. A second legal adult must be present to act as a witness and sign the bottom of this document.
For value received,   First Name*   Last Name* of   Home Address*   Address Line 2*   City*   State*   Zip*   hereinafter called the maker, promises to pay to Embody Dance Organization, Inc. of 420 Post Rd W Suite 202, Westport, CT 06880 the sum of   amount owed   by   Date of final payment

I. Repayment of such principal shall be made in the following manner:

Payment 1: Source:   First Name*   Last Name*   Method:
Amount (divide sum by

Payment 2: Source:   First Name*Last Name*   Method:   *
Amount: $100 Date: 4/1/2021

Payment 3: Source:   First Name*Last Name*   Method:   *
Amount: $100 Date: 5/1/2021

II. The maker may make payments to Embody Dance Conference LLC by check or via PayPal. If paying by check, the maker will make out all checks to Embody Dance Conference LLC and mail payments as addressed below:

Embody Dance Conference LLC
420 Post Rd W Suite 202
Westport, CT 06880

If paying via PayPal, the maker will pay Embody Dance Conference LLC via PayPal by sending payment to info@embodydanceconference.com

III. The maker assumes the responsibility of payments being on or before the above due dates. The maker promises to pay a late charge of $15.00 for each installment that remains unpaid more than 10 days after its due date.

IV. The maker agrees to pay the principal with late fee, together with reasonable attorney’s fees and other legal costs and charges for the collection of any amount due according to the terms of this note.

V. The maker agrees to inform Embody Dance Conference LLC of any change in their address.

VI. I, the maker, have read and agree to all conditions and terms contained herein.
Maker*

Clear
Witness of Notary*

Clear
Date*

MonthDayYear
Date
Date *

MonthDayYear
Date
Should be Empty:

Embody Payment Plan

Payment Plan Promissory Note